Faculty Bibliography

PURPOSE OF REVIEW/OBJECTIVE:To review the benefits, risks, and contraindications of traditional and new anesthesia approaches for hip fracture surgery and describe what is known about the impact of these approaches on postoperative outcomes. RECENT FINDINGS/RESULTS:This review describes general and spinal anesthesia, peripheral nerve block techniques used for pain management, and novel, local anesthesia approaches which may provide significant benefit compared with traditional approaches by minimizing high-risk induction time and decreasing respiratory suppression and short- and long-term cognitive effects. Hip fracture surgery places a large physiologic stress on an already frail patient, and anesthesia choice plays an important role in managing risk of perioperative morbidity. New local anesthesia techniques may decrease morbidity and mortality, particularly in higher-risk patients.

CASE/UNASSIGNED:A 51-year-old woman with an infected left humeral shaft recalcitrant nonunion presented 3 years after initial injury. This case report focuses on the staged treatment of a 17-centimeter (cm) humeral shaft nonunion with the induced membrane technique (IMT) using a unique fixation construct of dual locked plating around a humeral nail to provide long-lasting fixation and allow for bone graft consolidation. CONCLUSION/UNASSIGNED:Large segmental bone loss of the humerus can be treated with the IMT using nail-plate fixation constructs that allow for early mobilization, increased time for bone graft consolidation before hardware failure, and less frequent follow-up.

There has been a paradigm shift towards fixing the posterior malleolus in trimalleolar ankle fractures. This study evaluated whether a surgeon's preference to intraoperatively flip or not flip patients from prone to supine for medial malleolar fixation following repair of fibular and posterior malleoli impacted surgical outcomes. A retrospective patient cohort treated at a large urban academic center and level 1 trauma center was reviewed to identify all operative trimalleolar ankle fractures initially positioned prone. One hundred and forty-seven patients with mean 12-month follow up were included and divided based on positioning for medial malleolar fixation, prone or supine (following closure, flip and re-prep and drape). Data was collected on patient demographics, injury mechanism, perioperative variables, and complication rates. Postoperative reduction films were reviewed by orthopedic traumatologists to grade the accuracy of anatomic fracture reduction. Overall, 74 (50.3%) had the medial malleolus fixed prone, while 73 (49.7%) were flipped and fixed supine. No differences in demographics, injury details, and fracture type existed between the groups. The supine group had a higher rate of initial external fixation (p=0.047), longer operative time in minutes (p<0.001), and a higher use of plate and screw constructs for medial malleolar fixation (p=0.019). There were no differences in clinical and radiographic outcomes and complication rates. This study demonstrated that intraoperative change in positioning for improved medial malleolar visualization in trimalleolar ankle fractures results in longer operative times but similar radiographic and clinical results. The decision of operative position should be based on surgeon comfort.

PURPOSE/OBJECTIVE:To compare outcomes of patients with posterior tibial plateau fractures who underwent repair indirectly with an anterior approach to those who underwent direct repair with a prone "Lobenhoffer" operative approach. METHODS:A total of 44 patients with a posterior column tibial plateau fracture that underwent repair were identified. Twenty-two patients with 22 tibial plateau fractures were fixed using a prone Lobenhoffer approach. They were compared to 22 patients treated with an indirect reduction using a supine approach for similar fracture patterns. Data collection at minimum 1 year included: patient-reported outcome scores (SMFA), patient-reported pain, knee range of motion, complications and need for reoperation. Radiographs were reviewed for knee alignment, residual depression and fracture healing. RESULTS:All demographics were similar between the groups except BMI, which was lower in the prone group (P < 0.05). Fracture type according to age, Schatzker and three-column classification was matched between cohorts. There was no difference in outcomes including: pain, radiographic knee alignment, residual articular depression, functional outcome (SMFA), complications and need for reoperations. Knee flexion at 1 year was greater in the prone group (127.8 vs. 115.8; P = 0.018). In addition, surgical time was less in the prone group (mean 73.7 min vs. 82.3 min; P = 0.015). CONCLUSION/CONCLUSIONS:The Lobenhoffer approach with direct reduction of posterior fracture fragments for complex tibial plateau fractures is an excellent option for these injuries. It allowed for faster surgery with improved ultimate knee range of motion in posterior column tibial plateau fractures.

BACKGROUND:The purpose of the present study was to evaluate differences in demographic features and clinical outcomes between patients who sustained a typical versus atypical subtrochanteric femoral fracture. METHODS:We reviewed the records for a cohort of consecutive patients who had undergone operative treatment of a subtrochanteric femoral fracture. Fractures were classified as either "typical" or "atypical" on the basis of the criteria of the American Society for Bone and Mineral Research (ASBMR). All patients were treated with a similar surgical algorithm and postoperative protocol. Groups were compared on the basis of demographic features, injury characteristics, operative quality measures, postoperative complications and outcomes, and radiographic time to healing. Comparative analyses were performed to compare the typical and atypical cohorts. RESULTS:Of 220 subtrochanteric fractures, 165 (75.0%) were classified as typical and 55 (25.0%) were classified as atypical. The atypical cohort was predominately female and more likely to have bisphosphonate usage (odds ratio [OR], 7.975; [95% confidence interval (CI), 3.994-15.922]; p < 0.001) and fractures with lower-energy mechanisms (p < 0.001). Patients in the atypical cohort were more likely to be treated with a 10-mm cephalomedullary nail (CMN) (OR, 2.100 [95% CI, 1.119-3.939]; p = 0.020), whereas patients in the typical cohort were treated more frequently with an 11-mm CMN (OR, 0.337 [95% CI, 0.168-0.674]; p = 0.002). There were no differences between the groups in terms of other operative parameters; however, anatomic fracture reduction in neutral lateral alignment was achieved more frequently in the typical cohort (OR, 0.438 [95% CI, 0.220-0.875]; p = 0.018). There were no differences between the groups in terms of hospital quality measures, mortality rates, readmission rates, or complication rates (including implant failure [broken screw or nail] and fracture nonunion) (p = 1.00). Interestingly, there was no significant difference between the groups in terms of time to radiographic healing (260.30 ± 187.97 days in the typical group, compared with 246.40 ± 116.33 days in the atypical group) (OR, 0.999 [95% CI, 0.997-1.002]; p = 0.606). CONCLUSIONS:Despite differences in terms of demographic and injury characteristics, patients who sustain a subtrochanteric femur fracture can expect similar outcome profiles regardless of fracture type. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE:To compare the outcomes of patients with segmental bone loss who underwent repair with the induced membrane technique (IMT) with a matched cohort of nonunion fractures without bone loss. DESIGN/METHODS:Retrospective analysis on prospectively collected data. SETTING/METHODS:Academic medical center. PATIENTS/METHODS:Two cohorts of patients, those with upper and lower extremity diaphyseal large segmental bone loss and those with ununited fractures, were enrolled prospectively between 2013 and 2020. Sixteen patients who underwent repair of 17 extremities with segmental diaphyseal or meta-diaphyseal bone defects treated with the induced membrane technique were identified, and matched with 17 patients who were treated for 17 fracture nonunions treated without an induced membrane. Sixteen of the bone defects treated with the induced membrane technique were due to acute bone loss, and the other was a chronic aseptic nonunion. MAIN OUTCOME MEASUREMENTS/METHODS:Healing rate, time to union, functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA) and pain assessed by the Visual Analog Scale (VAS). RESULTS:The initial average defect size for patients treated with the induced membrane technique was 8.85 cm. Mean follow-up times were similar with 17.06 ± 10.13 months for patients treated with the IMT, and 20.35 ± 16.68. months for patients treated without the technique. Complete union was achieved in 15/17 (88.2%) of segmental bone loss cases treated with the IMT and 17/17 (100%) of cases repaired without the technique at the latest follow up visit. The average time to union for patients treated with the induced membrane technique was 13.0 ± 8.4 months and 9.64 ± 4.7 months for the matched cohort. There were no significant differences in reported outcomes measured by the SMFA or VAS. Patients treated with the induced membrane technique required more revision surgeries than those not treated with an induced membrane. CONCLUSION/CONCLUSIONS:Outcomes following treatment of acute bone loss from the diaphysis of long bones with the induced membrane technique produces clinical and radiographic outcomes similar to those of long bone fracture nonunions without bone loss that go on to heal. LEVEL OF EVIDENCE/METHODS:III.

PURPOSE/UNASSIGNED:This study aims to compare patients in whom fixation failure occurred via cut-out (CO) or cut-through (CT) in order to determine patient factors and radiographic parameters that may be predictive of each mechanism. MATERIALS AND METHODS/UNASSIGNED:This retrospective cohort study includes 18 patients with intertrochanteric (IT) hip fractures (AO/OTA classification 31A1.3) who underwent treatment using a single lag screw design intramedullary nail in whom fixation failure occurred within one year. All patients were reviewed for demographics and radiographic parameters including tip-to-apex distance (TAD), posteromedial calcar continuity, neck-shaft angle, lateral wall thickness, and others. Patients were grouped into cohorts based on the mechanism of failure, either lag screw CO or CT, and a comparison was performed. RESULTS/UNASSIGNED:=0.936) was observed between groups. A higher rate of DEXA (dual energy X-ray absorptiometry) confirmed osteoporosis (25.0% vs. 60.0%) was observed in the CT group, but without significance. CONCLUSION/UNASSIGNED:The mechanism of CT failure during intramedullary nail fixation of an IT fracture did not show an association with clinical data including patient demographics, reduction accuracy, or radiographic parameters. As reported in previous biomechanical studies, the main predictive factor for patients in whom early failure might occur via the CT effect mechanism may be related to bone quality; however, conduct of larger studies will be required in order to determine whether there is a difference in bone quality.

The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a risk stratification tool. We evaluated the STTGMA's accuracy in predicting 30-day mortality and the odds of unfavorable clinical trajectories among crash-related trauma patients. This retrospective cohort study (n = 912) pooled adults aged 55 years and older from a single institutional trauma database. The data were split into training and test data sets (70:30 ratio) for the receiver operating curve analysis and internal validation, respectively. The outcome variables were 30-day mortality and measures of clinical trajectory. The predictor variable was the high-energy STTGMA score (STTGMAHE). We adjusted for the American Society of Anesthesiologists Physical Status. Using the training and test data sets, STTGMAHE exhibited 82% (95% CI: 65.5-98.3) and 96% (90.7-100.0) accuracies in predicting 30-day mortality, respectively. The STTGMA risk categories significantly stratified the proportions of orthopedic trauma patients who required intensive care unit (ICU) admissions, major and minor complications, and the length of stay (LOS). The odds of ICU admissions, major and minor complications, and the median difference in the LOS increased across the risk categories in a dose-response pattern. STTGMAHE exhibited an excellent level of accuracy in identifying middle-aged and geriatric trauma patients at risk of 30-day mortality and unfavorable clinical trajectories.

This study compares outcomes of patients with Lisfranc injuries treated with screw only fixation constructs to those treated with dorsal plate and screw constructs. Seventy patients who underwent surgical treatment for acute Lisfranc injury without arthrodesis and minimum 6-month (mean >1-year) follow-up were identified. Demographics, surgical information, and radiographic imaging were reviewed. Cost data were compared. The primary outcome measure was the American Orthopedic Foot and Ankle Surgery (AOFAS) midfoot score. Univariate analysis through independent sample t tests, Mann-Whitney U, and chi-squared compared the populations. Twenty-three (33%) patients were treated with plate constructs and 47 (67%) with screw only fixation. The plate group was older (49 ± 18 vs 40 ± 16 years, p = .029). More screw constructs treated isolated medial column injuries compared to plate constructs (92% vs 65%, p = .006). At latest follow-up (mean 14 ± 13 months), all tarsometatarsal joints were aligned. There was no difference in AOFAS midfoot scores. Plate patients experienced longer operations (131 ± 70 vs 75 ± 31 minutes, p < .001) and tourniquet time (101 ± 41 vs 69 ± 25 minutes, p = .001). Plate constructs were more expensive than screw ($2.3X ± $2.3X vs $X ± $0.4X, p < .001) ($X is the mean cost of screws alone). Plate patients had a higher incidence of wound complications (13% vs 0%, p = .012). Treatment of Lisfranc fracture dislocation injuries with screws only demonstrated a higher value procedure as similar outcomes were found amidst lower implant costs. Screw only fixation required a shorter operative and tourniquet time with less frequent wound complications. Screw only fixations proved mechanically sound enough to achieve goals of repair without inferior outcomes.

BACKGROUND:The purpose of this study is to characterize the effects of head injuries amongst the middle-aged and geriatric populations on hospital quality measures, costs, and outcomes in an orthopedic trauma setting. METHODS:Patients with head and orthopedic injuries aged >55 treated at an academic medical center from October 2014-April 2021 were reviewed for their Abbreviated Injury Score for Head and Neck (AIS-H), baseline demographics, injury characteristics, hospital quality measures and outcomes. Univariate comparative analyses were conducted across AIS-H groups with additional regression analyses controlling for confounding variables. All statistical analyses were conducted with a Bonferroni adjusted alpha. RESULTS:A total of 1,051 patients were included. The mean age was 74 years, and median AIS-H score was 2 (range 1-6). While outcomes worsened and costs increased as AIS-H scores increased, the most drastic (and clinically relevant) rise occurs between scores 2-3. Patients who sustained a head injury warranting an AIS-H score of 3 experienced a significantly higher rate of major complications, need for ICU admission, inpatient and 1-year mortality with longer lengths of stay and higher total costs despite no differences in demographics or injury characteristics. Regression analysis found a higher AIS-H score was independently associated with greater mortality risk. CONCLUSION/CONCLUSIONS:AIS-H scores >2 correlate with significantly worse outcomes and higher hospital costs. Concomitant head injuries impact both outcomes and direct variable costs for middle-aged and geriatric orthopedic trauma patients. Clinicians, hospitals, and payers should consider the significant effect of head injuries on the hospitalization of these patients.